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Director's Report to the National Advisory Council on Drug Abuse - September, 2005

Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse

Participating in Family Activities Results in Less Drug Use

Dr. Nancy Petry and colleagues at University of Connecticut Health center examined data from 150 adults who had been randomized into a contingency management intervention in which completion of client elected goals received tangible reinforcement. The client selected the type of goals in which they participated during the twelve-week treatment period. People who engaged in at least three family-related activities per week were engaged in treatment longer, were abstinent for more weeks, and reported greater reductions in family conflict than people who engaged in fewer family related goals. Lewis, M.W. and Petry, N, Drug Alcohol Dependence, pp. 267-271, August 2005.

Financial Incentives for Participating in Drug Abuse Treatment Research Does Not Appear to Impact Participants Negatively

Dr. David Festinger and colleagues at the Treatment Research Institute randomly assigned drug abuse outpatients to receive payments of $10, $40, or $70 in one of two modalities, cash or gift certificate, for attending a research follow-up assessment session six months after treatment. Participants who attended received a randomly determined incentive and were then scheduled for a appointment 3 days later to detect new instances of drug use. New drug use and perceptions of coercion by participants were not affected by either the magnitude or the mode of the incentives, as had been commonly assumed. Higher incentives ($40, & $70) significantly improved the chance that a participant would attend the follow-up rates over the 10$ condition. Festinger, D.S., Marlowe, D.B., Croft, J.R., Dugosh, K.L., Mastro, N.K., Lee, P.A., Dematteo, D.S. and Patapis, N.S. Drug & Alcohol Dependence, pp. 275-281, June 2005.

Efficacy of Dose and Contingency Management Procedures in LAAM-Maintained Cocaine-Dependent Patients

Dr. Oliveto and colleagues at Yale University randomly assigned opioid and cocaine dependent participants (N=140) to one of the following in a 12 week clinical trial: 1) LAAM (30,30,39mg/MWF) with contingency management; 2) LAAM (30,30,39mg/MWF) without contingency management; 3) LAAM (100, 100,130mg/MWF) with contingency management; and 4) LAAM (100, 100, 130mg/MWF) without contingency management. Urine samples were collected 3 times per week. In contingency management, each urine negative for both opioids and cocaine resulted in a voucher worth a certain monetary value that increased for consecutively drug free urines. Vouchers were exchanged for mutually agreed upon goods and services. The groups did not differ on retention and baseline characteristics. Abstinence from both opioids and cocaine was greatest in the high dose LAAM plus contingency management group. However, contingency management procedures were not as effective in reducing cocaine use at the lower dose of LAAM. The results suggest that an efficacious maintenance dose may be necessary for contingencies to be effective in facilitating both opioid and cocaine abstinence in this dually dependent population. Oliveto, A., Poling, J., Sevarino, K.A., Gonsai, K.R., McCance-Katz, E.F., Stine, S.M. and Kosten, T.R. Drug and Alcohol Dependence, 79(2), pp. 157-165, August 1, 2005.

Moderators of Effects of Motivational Enhancements to Cognitive Behavioral Therapy

Dr. Rosenblum and colleagues at the Institute for Treatment and Services Research, National Development and Research Institutes, Inc, in New York, conducted a study in which patient treatment matching hypotheses were tested for substance users randomly assigned to a group cognitive behavioral therapy (CBT; n=114) or a group motivational intervention ( GMI; n=116). Treatment was scheduled twice weekly for 10 weeks. Using a patient attribute by treatment interaction design with a 15 week follow up, the study predicted that alexithymia, antisocial personality disorder, and network support for alcohol and drug use would be associated with less substance use for CBT subjects and that hostility and lower motivation would be associated with less substance use for GMI subjects. Three of the hypothesized moderators were empirically supported: alexithymia, network support for alcohol, and antisocial personality disorder. The results indicate the use of assessing specific patient attributes to better inform treatment recommendations. Rosenblum, A., Cleland, C., Magura, S., Mahmood, D., Kosanke, N. and Foote, J. American J. Drug and Alcohol Abuse. 31(1), pp. 35-38, 2005.

Cocaine Dependence and PTSD: A Pilot Study of Symptom Interplay and Treatment Preferences

Cocaine dependence and posttraumatic stress disorder ( PTSD) frequently co-occur; however, little is known about patients' perceptions of symptom connectedness and preferences for treatment. Dr. Sudie Back and colleagues at the Medical University of South Carolina, conducted a preliminary investigation of patients' perceptions of symptom interplay and their preferences regarding concurrent or sequential models of psychotherapy, therapy format, and treatment modalities. Participants were 23 individuals with comorbid cocaine dependence and PTSD. The majority (95.5%) reported a functional relationship between cocaine use and PTSD symptoms. Improvement in PTSD symptoms was typically ( 63.3%) associated with a decrease in cocaine use, and a worsening of PTSD symptoms was associated with an increase in cocaine use. In contrast, improvement/deterioration in cocaine use was not significantly related to subsequent improvement/deterioration in PTSD symptoms. This finding suggests that changes in PTSD symptoms may be an important risk factor to consider among individuals with comorbid cocaine dependence and PTSD. Approximately 41% preferred a concurrent model of therapy in which the cocaine use and PTSD were treated simultaneously in therapy. These findings highlight the functional relationship between these two disorders and have direct implications for treatment interventions. Back, S.E., Brady, K.T., Jaanimagi, U. and Jackson, J.L. Addict Behavior, June 9, 2005.

Anxiety Disorders among Patients with Co-occurring Bipolar and Substance Use Disorders

Dr. Kolodziej and colleagues at Harvard and Boston University examined the prevalence and nature of anxiety disorder among treatment seeking patients diagnosed with current bipolar and substance use disorders, and investigated the association between anxiety disorders and substance use. Among 90 participants diagnosed with bipolar disorder I ( n=75, 78%) or II ( n=15, 22%), 43 ( 48%) had a lifetime anxiety disorder, with posttraumatic stress disorder (PTSD) occurring most frequently (n=21, 23%). They found that those with PTSD, but not with the other anxiety disorders assessed, began using drugs at an earlier age and had more lifetime substance use disorders, particularly cocaine and amphetamine use disorders, than those without PTSD. Most participants with PTSD were women, sexual abuse was the most frequently reported index trauma, and the mean age of the earliest index trauma occurred before the mean age of initiation of drug use. These findings highlight the heterogeneity of dually diagnosed patients, and the importance of further investigating the ramifications of a trauma history among those who are diagnosed with bipolar and substance use disorders. Kolodziej, M.E., Griffin, M.L., Najavits, L.M., Otto, M.W., Greenfield, S.F. and Weiss, R.D. Drug and Alcohol Dependence, In Press, Corrected Proof Available Online May 3, 2005.

Behavioral Treatment Approaches for Methamphetamine Dependence and HIV-Related Sexual Risk Behaviors Among Urban Gay and Bisexual Men

Dr. Shoptaw and colleagues evaluated the efficacy of four behavioral drug abuse treatments for reducing methamphetamine use and sexual risk behaviors in methamphetamine-dependent gay and bisexual men. Participants (N=162) were assigned to 16 weeks of one of four behavioral treatments: standard cognitive behavioral therapy (CBT), contingency management (CM), combined cognitive behavioral therapy and contingency management (CBT+CM) and a culturally tailored cognitive behavioral therapy (GCBT). CM and CBT+CM conditions were statistically better than CBT during treatment in retention, in longest period of consecutive urine samples negative for methamphetamine metabolites, and in the Treatment Effectiveness Score. GCBT significantly reduced unprotected receptive anal intercourse during the first four weeks of treatment. Between-group differences found during treatment, disappeared at follow-up with overall reductions in outcomes sustained to one-year. The authors conclude that among high-risk methamphetamine-dependent GBM, drug abuse treatments produced significant reductions in methamphetamine use and sexual risk behaviors. Drug abuse treatments merit consideration as a primary HIV prevention strategy for this population. Shoptaw, S., Reback, C.J., Peck, J.A., Yang, X., Rotheram-Fuller, E., Larkins, S., Veniegas, R.C. Freese, T.E. and Hucks-Ortiz, C. Drug and Alcohol Dependence, 9, pp. 125-134, 2005.

Brief Motivational Intervention for Adolescent Smokers in Medical Settings

Investigators from Brown University conducted a study designed to determine the efficacy of two brief behavioral interventions for smoking cessation in adolescents treated in a hospital outpatient clinic or Emergency Department. Patients aged 14-19 years (N=85) were randomly assigned to receive either one session of motivational interviewing (MI) or standardized brief advice (BA) to quit smoking. Patients were proactively screened and recruited and not seeking treatment for smoking. Follow-up assessments were conducted at 1, 3, and 6 months post-intervention. Adolescents in both conditions reported smoking reductions at all three follow-ups. Those in the MI group also showed reduced cotinine levels at 3 months, unlike those in BA, and both groups showed reduced cotinine levels at 6 months. Overall, abstinence rates were low and did not differ between groups at 1 or 3 months. At 6 months, self-report data indicated that abstinence rates were significantly higher for the MI group than the BA group, but this difference was not confirmed biochemically. Groups did not differ in biochemically confirmed abstinence at any follow-up. The low rates of abstinence found are consistent with findings from other adolescent smoking cessation trials, which have generally effected only minimal change even among treatment-seeking adolescents. Colby, S.M., Monti, P.M., O'Leary, Tevyaw, T. Barnett, N.P., Spirito, A., Rohsenow, D.J., Riggs, S. and Lewander, W. Addictive Behaviors, 30, pp. 865-874, 2005.

Smoking Stage of Change and Interest in an Emergency Department-based Intervention

This study sought to assess the prevalence and predictors of smoking stage of change and interest in an ED-initiated smoking intervention. Patients in an emergency department were interviewed immediately before discharge from the ED or transfer to an inpatient floor. Among those interviewed, 581 (40%) were current smokers, 117 (21%) were in precontemplation stage, 241 (43%) were in contemplation stage, and 197 (36%) were in preparation stage. Sixty-two percent endorsed at least "somewhat" agreement that smoking counseling should be provided in the ED, while nearly one half (49%) agreed to stay 15 extra minutes to do so. Fifty-nine percent of treating physicians/nurses screened patients for smoking status, however only 8% of patients reported receiving information about quitting. The findings indicate that most smokers have at least some desire to change and appear interested in ED smoking cessation counseling. Due to limited efforts in the ED, efforts may be better spent on counseling patients who are receptive and ready to change. Boudreaux, E.D., Baumann, B.M., Friedman, K. and Ziedonis, D.M. Acad Emerg Med, 12, pp. 211-218, 2005.

Intentions to Quit Smoking Change Over Short Periods of Time

This study intended to assess the stability of intention to quit smoking over a 30-day period. One-hundred and fifteen US and Swedish smokers were randomized to complete Stage of Change (SOC) or ladder scales of intentions to quit at either 0, 7, 14 and 30 days or at 0 and 30 days in the absence of intervention. The results indicate that measures of intention to quit are often unstable over short periods of time. The results also indicate the four-assessment group had more progression in intention to quit than the two-assessment group, indicating that repeated measurement can influence intention outcomes. Hughes, J.R., Keely, J.P., Fagerstrom, K.O. and Callas, P.W. Addictive Behaviors, 30, pp. 653-662, 2005.

Distress Tolerance and Early Smoking Lapse

This paper discusses the theoretical and clinical implications of distress tolerance in smoking cessation. Whereas past work on smoking relapse has largely addressed the role of withdrawal symptoms and negative affect, the model presented by Brown et al. emphasizes that the way in which one reacts to the discomfort of nicotine withdrawal is a more promising avenue of investigation. Development of a specialized and novel behavioral distress tolerance treatment for early smoking lapsers is proposed. Brown, R.A., Lejuez, C.W., Kahler, C.W., Strong, D.R. and Zvolensky, M.J. Clin Psychol Rev, 6, pp. 713-733, 2005.

The Effects of a Prison Smoking Ban on Smoking Behavior and Withdrawal Symptoms

This study investigated symptoms of distress and nicotine dependence as predictors of nicotine withdrawal symptoms among 188 incarcerated male smokers during a mandated smoking ban. Participants were assessed at three time periods: baseline, 4 days after the smoking ban, and 1 month after the smoking ban. Most smokers (76%) continued to smoke following the smoking ban. Smokers after the ban were more nicotine dependent and reported more withdrawal symptoms than participants that quit. An interaction was found such that distressed smokers had the highest level of nicotine withdrawal. The authors surmise that the low compliance with the smoking ban was due to low motivation to enforce the ban on the part of prison employees, since they were affected by the ban as well. These results have implications for how smoking bans are instituted in prison settings. Cropsey, K.L. and Kristeller, J.L. Addictive Behaviors, 30, pp. 589-594, 2005.

Acceptance of Nicotine Dependence Treatment Among Currently Depressed Smokers

Dr. Haug and colleagues at the University of California, San Francisco conducted this study to examine specific characteristics of psychiatric outpatients with depressive disorders who either accepted or refused available smoking cessation treatment. The sample (N=154) participated in a repeated contact experimental condition where they received a stage-based expert system program to facilitate treatment acceptance and were then offered smoking treatment, consisting of behavioral counseling, nicotine patch, and bupropion. Acceptors (N=53) were defined as those accepting behavioral counseling and pharmacological treatment at some point during the 18-month study, whereas refusers (N=101) received only the expert system. The number of days to treatment acceptance was significantly predicted by stage of change, with those in preparation entering treatment more quickly than contemplators or precontemplators. The variables most strongly associated with accepting treatment were current use of psychiatric medication and perceived success for quitting. Severity of depressive symptoms, duration of depression history, and history of recurrent depression were not related to treatment acceptance. The authors suggest that the findings have implications for the psychiatric assessment and treatment of smokers in clinical settings. Psychiatric medication may play a significant role in smoking cessation treatment acceptance by currently depressed smokers. Haug, N.A., Hall, S.M., Prochaska, J.J., Rosen, A.B., Tsoh, J.Y., Humfleet, G., Delucchi, K., Rossi, J.S., Redding, C.A. and Eisendrath, S. Nicotine and Tobacco Research, 7, pp. 217-224, 2005.

Contingency Management and Cognitive-Behavioral Treatment for Adolescent Marijuana Abuse Shows Promise

Investigators at the University of Vermont published data on an initial sample of 19 adolescents participating in a Stage-I treatment-development study targeting marijuana abuse and associated behavior problems. Adolescents participated in a 14-week treatment consisting of incentives for adolescent abstinence, parent involvement in delivering contingencies, clinic-delivered incentives to parents for participation in treatment, and individual cognitive-behavioral treatment for adolescents. The results suggest that families had high levels of participation in treatment, and that abstinence from marijuana increased significantly from treatment entry to completion (improving from 37% abstinence to 74% abstinence). This study reports on a unique combination of two behavioral interventions found to be beneficial in treating drug abuse-contingency management and family involvement-and demonstrates that the two can be efficacious in treating adolescent marijuana abuse. Kamon, J., Budney, A. and Stanger, C. Journal of the American Academy of Child and Adolescent Psychiatry, 44, pp. 513-521, 2005.

Researchers Should Evaluate Costs of Treatment in Addition to Efficacy and Effectiveness

Recognizing the role of cost in the availability and dissemination of treatments for drug abuse and related co-morbidities, Dr. William Fals-Stewart of the Research Triangle Institute and colleagues published guidelines to assist clinical researchers in including cost evaluations in their studies. Using marriage and family treatments as a model, the authors outline user-friendly guidelines to identify and define key constructs (i.e., cost, benefit, effectiveness), and offer recommendations of how to assess and analyze these constructs. This paper serves as a valuable tool in equipping researchers to design comprehensive studies of drug abuse treatment. Fals-Stewart, W., Yates, B. T. and Klosterman, K. Journal of Family Psychology, 19, pp. 28-39, 2005.

Ecologically Based Family Therapy Reduces Drug Abuse among Substance Abusing Runaway Adolescents

Dr. Natasha Slesnick, recently joining the faculty at Ohio State University, and colleague Jillian L. Prestopnik, report on the efficacy of a family-based behavioral treatment for substance abuse among runaway teens. Substance-abusing teens were recruited at a homeless shelter, and 124 were randomly assigned to receive Ecologically Based Family Therapy (EBFT) or to receive services as usual (SAU). Teens receiving EBFT had significantly greater reductions in substance use than did teens receiving SAU, with those reporting a history of physical or sexual victimization achieving even better outcomes in EBFT. Other areas of functioning (psychiatric diagnoses, delinquent behaviors, family functioning, knowledge of HIV risk, etc.) improved significantly for teens receiving either EBFT or SAU. These results suggest that a family-based behavioral treatment has potential to improve substance abuse among a high-risk population of runaway teens, and that there may be several avenues to intervening in other areas of functioning. Slesnick, N. and Prestopnik, J. L. Journal of Adolescence, 28, pp. 277-298, 2005.


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